SA Ear and Pinna Surgery Flashcards
List indications for SA ear and pinna surgery.
Allergic skin disease of ext. ear canal.
Discoid Lupus Erythematosus of pinna.
Pemphigus of pinna.
Congenital ear canal stenosis.
Pendulous ears.
Hair ear canals.
Secondary ear canal stenosis.
‘Cauliflower’ ear - secondary to aural haematoma.
Other traumatic deformity.
Neoplasia of the pinna, external ear canal, middle ear, inner ear, para-aural region:
- benign = ceruminous gland adenomas, papillomas, inflammatory polyps.
- malignant = SCC, ceruminous gland adenocarcinoma.
Infectious otitis (externa most commonly) - bacterial = staph/strep, pseudomonas.
- parasitic = mites e.g. Otodectes / demodex / Sarcoptes / Harvest mites.
- fungal e.g. Malassezia / ringworm (pinna).
Inflammation due to - cholesteatoma, FB, inflammatory polyps, solar dermatitis, viral e.g. Distemper.
Trauma - self, surgical, accident, fighting, most commonly pinna but may be external ear canal, most commonly results in aural haematoma, pinnal laceration, ear canal avulsion (para-aural abscess secondarily).
Where do inflammatory polyps tend to occur?
Nasopharynx / oropharynx.
Auditory tube.
- pop into nasopharynx/oropharynx.
- pop into middle ear.
Middle ear.
- stay in middle ear.
- pop through ear drum into external ear canal.
Types of surgery to be performed on the ear.
Aural haematoma sutures.
Lateral wall resection.
Pinnal repair.
Pinnectomy.
Polyp traction.
TECA-LBO.
Ventral bulla osteotomy.
Vertical ear canal ablation.
Other than the most common cause of trauma, what else could cause an aural haematoma?
Immune-mediated / coagulopathy.
Aural haematoma history.
Head shaking - before or after haematoma formation?
Scratching.
Underlying dermatopathy?
Trauma.
Pain.
Swelling.
Reason for pruritus.
Factors affecting choice of Tx of aural haematoma?
Haematoma size / age.
Any patient co-morbidities?
Patient temperament.
Owner finances.
Owner practicalities.
Surgeon preference.
Cosmetic appearance.
Aural haematoma surgery step-by-step.
Linear skin incision to evacuate blood and clot.
Flush with saline and try to remove fibrinous material too.
Bring incision edges together, w/ non-absorbable suture on a straight needle – simple interrupted sutures through from lateral side of pinna, through skin, articular cartilage, through medial pinnal skin and return other way so knot on lateral side of pinna –> important for floppy-eared dogs so knot not on medial side and tickling the side of the neck, increasing likelihood of interference.
Keep sutures parallel to the incision as not to disrupt the blood supply from the base of the pinna to the tip, risking necrosis.
Sutures also help to close dead space.
Keep sutures in minimum 2 weeks, or push to 3 weeks.
Most common surgical variations for aural haematoma.
Straight vs curvilinear.
- curvilinear thought to prevent deformity in healing – no conclusive evidence found.
Suture pattern = full thickness vs partial thickness – no advantage of partial thickness found.
Suture material = Absorbable vs non-absorbable – based on patient temperament or owner constraints.
Added extras - e.g. buttons / tubing – no evidence that these are beneficial. Concern of pressure necrosis.
Lateral wall resection.
Take lateral wall of vertical ear canal only.
Only indicated if abnormality is on the outside edge of vertical ear canal.
- only really some form of inflammatory lesion or neoplastic lesion – rare.
Patient in lateral recumbency.
Position with rolled towels under neck to get ear canal in good position.
Prep ear and around ear.
U-shaped skin incision to expose lateral wall of vertical canal.
Two parallel cartilage incision and reflect lateral edge of vertical ear canal ventrally to for ‘drainage board’.
Cut off excess lateral wall as required.
Close skin.
Suture ‘drainage board’ to the skin.
Vertical ear canal ablation.
Lateral and medial walls removed.
Leave horizontal ear canal behind.
Appropriate when disease isolated to vertical ear canal only.
Patient in lateral recumbency with towel rolls under neck, aseptic skin prep.
T-shaped skin incision, extending just below the horizontal ear canal, to expose lateral wall of vertical canal.
Cut out ear canal around the back of it, leaving 1-2cm of vertical ear canal behind.
Submit removed canal for histology.
2 parallel incisions down remaining vertical ear canal, reflecting lateral ventrally to form ‘drainage board’ and suturing to the skin.
Close skin, and close in the medial wall.
TECA and lateral bulla osteotomy.
Take whole ear canal - vertical and horizontal ear canal - and lateral wall of the bulla.
Patient in lateral recumbency, with towel rolls under neck, aseptic skin prep.
Lateral T-shaped skin incision.
Dissect out entire ear canal down to the external auditory meatus, cutting around back of vertical ear canal, giving clear view of lateral bulla.
Strip away bottom of bony hole to allow access to bulla to strip away secretory tissue that lines it.
Perform lateral bulla osteotomy.
Close the skin.
Ventral bulla osteotomy.
Indicated for disease affecting middle ear only e.g. inflammatory polyp.
Patient in lateral recumbency, with towel rolls under neck, aseptic skin prep.
Ventral skin incision.
- Reasons for pinnectomy.
- Process.
- Neoplasia - curative or palliative.
Neutering status.
Trauma. - dissect away the pinna tip.
Undermine lateral skin rather than medial as medial very closely adhered to the articular cartilage.
Dissect away a further 2mm of cartilage.
Elevate lateral skin enough to allow it to come over the top of the cartilage and suture in place.
List the main complications associated with ear surgery and their treatment.
Failure to cure - e.g. aggressive neoplasia, wrong procedure chosen - Tx Sx or palliation.
Healing issue e.g. leaving residually infected tissue resulting in para-aural abscess, patient interference, poor technique - Tx conservative or further Sx.
Anatomical - e.g. cauliflower ear, stenosis, traumatic ear canal evulsion - Tx conservative management or more Sx.
Infection - e.g. recurrence of primary condition or secondary infection - e.g. culture and targeted ABX, maybe more Sx.
Haemorrhage - many blood vessels e.g. branches of jugular and carotid, retroglynoid vein within bulla - use of ligatures and electrosurgery, bone wax, and pressure to manage in surgery.
Neurological - frequently get a temporary neuropraxia due to bruising causing drooping of face etc, sometimes permanent. Should warn owners of risks. Sympathetic branches in the middle ear - could get Horner’s. Vestibular nerve damage causes balance issues. Cochlear nerve damage causes hearing issues which may not be as noticeable. Conservative management, palliative.
